- Email: [email protected]
Surgical treatment of the boxer's fracture: transverse pinning versus intramedullary pinning
ARTICLE IN PRESS SURGICAL TREATMENT OF THE BOXER’S FRACTURE: TRANSVERSE PINNING VERSUS INTRAMEDULLARY PINNING M. WINTER, T. BALAGUER, C. BESSIE`RE, M. CARLES and E. LEBRETON From the Department of Traumatology and Orthopaedic surgery, St Roch hospital, University Hospital of Nice, France, the Department of Plastic, Reconstructive and Hand Surgery, St Roch Hospital, University Hospital of Nice, France and the Department of Anesthesiology, Archet II Hospital, University Hospital of Nice, France
The purpose of this study was to compare the surgical treatment of fractures of the little finger metacarpal neck, or ‘‘Boxer’s’’ fractures, by transverse pinning and intramedullary pinning. Thirty-six patients with fracture of the neck of the fifth metacarpal were included in a prospective comparative randomised study. A palmar splint was applied for 1 week after both procedures. Patients began physiotherapy three times per week for 30 days. The patients were evaluated clinically six times after surgery, up to the 90th day, with X-ray assessment on days 8, 45 and 90. The study showed that intramedullary pinning gave better functional outcomes than transverse pinning, although the former was more technically demanding. Journal of Hand Surgery (European Volume, 2007) 32E: 6: 709–713 Keywords: boxer’s fracture, metacarpal bone, transverse pinning, intramedullary pinning
Fractures of the neck of the fifth metacarpal, the socalled ‘‘Boxer’s Fracture’’, are very common injuries of the hand. The patients are usually active young men and these are typical injuries of aggression/alcohol intake (Greer and Williams, 1999; Mercan et al., 2004). Commonly, the dominant hand is the punching hand and this hand is affected. When palmar angulation exceeds 451, or when the patient presents a rotational deformity of the little finger in flexion, reduction, with or without surgical treatment, is mandatory (Ali et al., 1999). Foucher et al. (1976) reported fixation of these fractures by the insertion of fine K-wires antegradely to avoid the metacarpal articular surface. Foucher (1995) later reported a series of 66 cases treated in this manner and called this the ‘‘Bouquet’’ technique. Berkman and Miles (1943) first described the transverse pinning technique of little finger metacarpal neck fracture fixation in which several K-wires are passed transversely between the fifth and the fourth metacarpal to stabilise the fracture. It is known that these techniques are both efficient, but no comparison between them has been published. The purpose of this prospective study was to compare the two procedures in terms of functional and radiological outcome.
closed and simple fracture of the neck of the little finger metacarpal bone. Open fractures and fractures extending to the metacarpal shaft, or to the articular surface, were excluded from the study. Patients presenting with multiple injuries, fifth metacarpal malunion and selfinflicted injuries were not included in the study. Rotational deformity of the little finger was assessed clinically. In flexion, malrotation was recorded if the little finger was not oriented towards the scaphoid tubercle. In extension, the plane of orientation of the fifth finger nail relative to the other finger nails was noted: malrotation was recorded if these were not parallel. The palmar angular displacement of the fracture was measured on a lateral oblique X-ray with a goniometer placed on the dorsal cortical line of the metacarpal. Surgery was indicated if clinical malrotation of the little finger existed, or if the palmar angulation of the fracture exceeded 301. Operative procedure Patients underwent either transverse pinning or intramedullary pinning by the Bouquet technique. Infraclavicular brachial block anaesthesia was used in all cases. The technique chosen was allocated using a randomisation table. Each patient was registered in the table in the order of his/her inclusion in the study and allocated to one or other treatment group accordingly. Before inclusion, a written consent was obtained and the patient was informed about the surgical procedure. Patients were operated on by the senior surgeons of the department or by junior surgeons under supervision of a senior surgeon.
PATIENTS AND METHODS Patients The study was of a consecutive series of patients during a period of 12 months between 2003 and 2004. The clinical criterion for inclusion was a recent, isolated, 709
ARTICLE IN PRESS 710
Intramedullary pinning (the ‘Bouquet’ technique) For intramedullary pinning, three K-wires, of diameter 1 mm were used. These wires were contoured in order to obtain a 201 distal angulation. A small incision was made at the level of the carpometacarpal joint. After drilling a hole in the base of the little finger metacarpal, the wires were introduced into the metacarpal shaft. The distal angulation of the first wire was oriented dorsally. The two other wires were oriented in a radial and an ulnar direction, respectively. Clinical and X-rays checks of the adequacy of fracture fixation and the rotational position of the finger were carried out. The K-wires were then bent, cut and buried subcutaneously (Fig 1). Transverse pinning For transverse pinning, two K-wires of diameter 1.5 mm were used. The first K-wire was introduced through the ulnar border of the hand and passed from the little to the ring metacarpal shaft, approximately 10 mm proximal to the fracture. After reduction, the second K-wire was introduced through the ulnar border of the hand and passed from the little to the ring metacarpal head, avoiding the articular surfaces. This second wire was passed parallel to the first. The position of the finger in extension and flexion was then examined to check the rotation. Final clinical and X-ray checks of the adequacy of fracture fixation and the rotational position
Fig 1 Intramedullary pinning of a little finger metacarpal neck fracture.
Fig 2 Transverse pinning of a little finger metacarpal neck fracture.
THE JOURNAL OF HAND SURGERY VOL. 32E No. 6 DECEMBER
2007
of the finger were carried out. The K-wires were then cut and buried subcutaneously (Fig 2). Postoperatively, as recommended by Galanakis et al. (2002), a palmar splint was applied for 1 week after both procedures in order to assist healing of the soft tissues and to avoid postoperative displacement of the fracture (Faraj and Davis, 1999). After removal of the splint, patients began physiotherapy three times per week with the little and ring fingers buddy-strapped. The buddy-strapping was removed at the day 30 examination. The surgical stabilisation enables such early mobilisation of the hand to avoid stiffness without risk of secondary displacement (Konradsen et al., 1990; Vichard et al., 1981). After both procedures, the K-wires were removed 6 weeks after surgery under local anaesthesia. The patients were evaluated clinically on days 8, 15, 30, 45, 60 and 90 after surgery, with X-ray assessment, using an anteroposterior view and a lateral oblique hand X-ray, on days 8, 45 and 90. Pain was evaluated at each visit using a visual analogue scale from 0 to 10 in which 0 was no pain at all and 10 was the worst pain the patient could imagine. Active and passive ranges of motion of all three joints of the fifth ray were measured individually with a goniometer at each review by the physiotherapist. The grip strength of both hands was measured with a Jamart dynamometer on days 15, 30, 45, 60 and 90 after surgery. Postoperative rotation of the little finger was evaluated using the same criteria as were used for preoperative assessment.
ARTICLE IN PRESS SURGICAL TREATMENT OF THE BOXER’S FRACTURE
711
At each X-ray review, the angulation of the fracture was measured on lateral oblique hand X-rays. Fracture union was sought at each X-ray review. Fracture was considered as united when bone trabeculae crossing the fracture were noticed. Patient satisfaction was evaluated at the last review as excellent, good, fair or poor. If present, complications were noticed at each review. Data were expressed as mean and lower to upper values. The statistical tests used were a Fisher’s exact test, a Mann Withney U-test or a repeated measures ANOVA if required. A p Value under 0.05 was considered as significant. Because of the lack of previously published data, we were unable to calculate a sample size for this preliminary study.
RESULTS Thirty-six patients were included during a period of 12 months. Eighteen underwent transverse pinning and 18 underwent intramedullary pinning. All the patients were men, of mean age 31.4 (range 18–65) years. Twenty-four patients presented with a rotational deformity of the little finger. The average palmar angulation of the fracture preoperatively was 531 (range 301–901). 300 250
transverse intramedullary 246
TAM (degrees)
280 257
280 261
Day 60
Day 90
233
226
213
200
274
262
196 169
150 100 50 0
Day 8
Day 15
Day 30
Day 45
Fig 3 Comparison of total active motion (TAM) between the two groups.
The average period of immobilisation was 8.6 (range 0–30) days. Mean follow-up was 2.7 (range 2–3) months. The two groups were comparable in terms of follow-up duration. At final follow-up, two patients had residual pain measuring 1 and 4 on the visual analogue scale, respectively. Both had been treated by transverse pinning. At final follow-up, the mean total passive motion was 2851 (range 2001–3251) and the mean total active motion (TAM) was 2701 (range 1901–3101). All of the patients achieved full extension of the little finger. TAM showed a significant difference between the two groups, with a better result in the intramedullary pinning group (p ¼ 0.02) (Fig 3) (Table 1). The active range of motion of the metacarpophalangeal (MCP) joint was also significantly different between the two procedures, with a better result in the retrograde intramedullary pinning (p ¼ 0.0037) (Fig 4) (Table 1). One patient in the intramedullary pinning group removed his splint immediately after leaving the hospital and two patients in the transverse pinning group kept their splint on for one month because they did not come for review until this date. Grip strength was stronger after intramedullary pinning than after transverse pinning, but the difference was not statistically significant (Table 1). No patients had malrotation of the little finger postoperatively. A residual palmar angulation was found in 12 patients, with a mean palmar angulation of 91 (range 51–201). Five of the 18 patients in the transverse pinning group still had a mean palmar angulation of 101 (range 51–201). Seven of the 18 patients in the intramedullary pinning group still had a mean palmar angulation of 81 (range 51–151). Two patients from the transverse pinning group suffered secondary displacements of the fractures at the first X-ray assessment. However, this did not influence the postoperative care, because the angulations were minimal, and there was no malrotation. All fractures united within the period of 6 weeks. In terms of patient satisfaction, 28 patients considered their result as good or excellent. Data about satisfaction was absent for three patients. Thirteen of 17 patients in
Table 1—Comparative data of the two groups
Age mean (range) (years) Pre-operative angulation (1) Rotational problems Postoperative immobilization (days) TAM at final follow-up Active ROM MCPj at final follow-up Percentage of contralateral grip strength Statistically significant difference.
Intramedullary fixation (n ¼ 18)
Transverse fixation (n ¼ 18)
p Value
30.8 (18–65) 54.7 (30–90) 67% 7 (SD ¼ 2.3) 2791 (SD ¼ 11.9) 941 (SD ¼ 5.9) 92%
32 (20–49) 50.8 (30–70) 67% 10 (SD ¼ 7.7) 2611 (SD ¼ 36.5) 81.51 (SD ¼ 19.4) 83%
0.66 0.09 0.12 0.02 0.0037 0.06
ARTICLE IN PRESS 712
THE JOURNAL OF HAND SURGERY VOL. 32E No. 6 DECEMBER
100
transverse
ROM MCP joint (degrees)
90
intramedullary
80
78
80
68
70
95
94
90
82
66 60
60
48
50 40
42 36
30 20 10 0 Day 8
Day 15
Day 30
Day 45
Day 60
Day 90
Fig 4 Comparison of active ranges of motion of the MCP joint between the two groups.
the transverse pinning group and 15 of 16 patients in the intramedullary pinning group for whom satisfaction data was available had good or excellent results. Three poor and one fair result were noted in the transverse pinning group. One fair result was found in the intramedullary group (Table 1). There were no postoperative infections or digital nerve neuropraxias in either group. One patient in the transverse pinning group developed CRPS type 1 (syn. reflex sympathetic dystrophy, algodystrophy) after having worn his splint for 4 weeks without coming for review. This patient was involved in worker’s compensation. In respect of age, the angulation of the fracture, the malrotation, the time of immobilisation, the grip strength and the postoperative pain at final follow-up, there were no significant differences between the two groups.
DISCUSSION Fractures of the neck of the fifth metacarpal bone usually occur as a result of punching or in a fall (Greer and Williams, 1999). This injury has been described as ‘‘a tolerable fracture in an intolerable patient’’ (Mercan et al., 2004). Palmar displacement of the fifth metacarpal head and metacarpal shortening as a result of this fracture can occasionally have detrimental effects on hand function (Ali et al., 1999; Birndorf et al., 1997; Meunier et al., 2004). According to biomechanical studies, such displacement can alter the intrinsic muscle and the tendon balance, leading to a loss of grip strength and an extension deficit. The management of the boxer’s fracture is still controversial. Conservative treatment gives good results for fractures presenting with small displacement (Lowdow, 1986; McKerrel et al., 1987). Ali et al. (1999) and Birndorf
2007
et al. (1997) suggested that 301 is the upper limit of acceptable angulation of palmar displacement of such fractures. With respect to this trial, we included all patients with angulation of 301 or more, although the degree of angulation at which active treatment is considered to be mandatory remains controversial. Rotational displacement of the fifth ray following such fractures typically requires reduction. Recently, Smith et al. (2003) have shown that soft tissue swelling can induce a rotational problem by itself, without any fracture. We believe it is important to re-examine these patients after a week of treatment intended to reduce swelling. In face of severely displaced fractures, some authors suggest treatment by external reduction followed by immobilisation (Trabelsi et al., 2001). Unfortunately, external manipulation, even protected by a cast, often leads to secondary displacement (Lowdow, 1986). Many different surgical procedures have been described for treating this fracture (Berkman and Miles, 1943; Calder et al., 2000; Faraj and Davis, 1999; Foucher et al., 1976), but two attitudes can be identified. The first consists in using the ring finger metacarpal bone as a splint to maintain the fracture reduction using transverse K-wiring. The second is to stabilise the little finger metacarpal itself after adequate reduction by use of techniques of direct bone fixation, including axial, intramedullary K-wiring (the ‘Bouquet’ technique). Transverse pinning has been described by a number of authors (Berkman and Miles, 1943; Lamb et al., 1973; Mitz et al., 1981; Waugh and Ferrazano, 1943). The technique was described most precisely by Lamb et al. (1973). It is an easy procedure, which has many advantages: it is simple and quick, it provides good stability, is not very painful and has a low learning curve for the surgeon. One the other hand, it has some problems. The distal K-wire may damage the MCP articulation, especially for distal fractures. Introducing a K-wire through the intermetacarpal space may damage the interosseous muscles. Involvement of the ring metacarpal in the fixation makes movement between the two ulnar metacarpal bones impossible and, so, may reduce mobility of the hand. This, perhaps, is the reason for the poorer functional outcome with this technique when compared to intramedullary pinning. All of the patients in this series were operated on under brachial plexus block. However, transverse pinning can easily be done under local anaesthesia. Intramedullary pinning of the fifth metacarpal bone was described by Foucher et al. (1976). Later, the senior author published a series of 66 patients treated in this way with good results (Foucher, 1995). Since then, many other series using intramedullary pinnings have been described (Frere et al., 1982; Barry et al., 1991; Beal et al., 1991; Faraj and Davis, 1999; Manueddu and Della Santa, 1996). This procedure is more demanding technically than transverse pinning and, therefore, the surgeon has a more definite learning curve. Complications such as
ARTICLE IN PRESS SURGICAL TREATMENT OF THE BOXER’S FRACTURE
articular surface damage are more frequent with this technique. The surgical approach may also endanger branches of the dorsal branch of the ulnar nerve. Nevertheless, with the ring and little finger rays remaining independent, motion of both rays remains excellent. This procedure provides solid reduction and gives good anatomical reduction and, so, good results. This study suggests that intramedullary pinning is a particularly efficient procedure for treatment of the boxer’s fracture. Although more demanding, it has shown better results than transverse pinning. The difference between the two techniques in terms of early motion is probably explained by the independent mobility of the two metacarpal bones. Two weeks after removal of the wires, we noted that the difference of TAM and TPM between the two groups decreases. However, at 3 months, the functional results remained slightly better in the intramedullary pinning group. References Ali A, Hamman J, Mass DP (1999). The biomechanical effects of angulated boxer’s fractures. Journal of Hand Surgery, 24A: 835–844. Barry P, Regnard PJ, Bensa P (1991). Bundled wiring in fractures of the neck of the fifth metacarpal: 5 cases. Annales de Chirurgie de la Main et du Membre Supe´rieur, 10: 469–475. Beal D, Rongieres M, Mansat M (1991). Bundled central medullary bone wiring. Method of choice in the treatment of fractures of the neck of the fifth metacarpal necessitating a reduction: 30 cases. Annales de Chirurgie de la Main et du Membre Supe´rieur, 10: 463–468. Berkman EF, Miles GH (1943). Internal fixation of metacarpal fractures exclusive of the thumb. Journal of Bone and Joint Surgery, 25: 816–821. Birndorf MS, Daley R, Greenwald DP (1997). Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. Plastic and Reconstructive Surgery, 99: 1079–1083. Calder JDF, O’Leary S, Evans SC (2000). Antegrade intramedullary fixation of displaced fifth metacarpal fractures. Injury, 31: 47–50. Faraj AA, Davis TRC (1999). Percutaneous intramedullary fixation of metacarpal shaft fractures. Journal of Hand Surgery, 24B: 76–79. Foucher G (1995). ‘‘Bouquet’’ osteosynthesis in metacarpal neck fractures. A serie of 66 patients. Journal of Hand Surgery, 20A: 86–89. Foucher G, Chemorin C, Sibilly A (1976). Nouveau proce´de´ d’oste´osynthe`se original dans les fractures du tiers distal du cinquie`me me´tacarpien. Nouvelle Presse Me´dicale, 17: 1139–1140.
713
Frere G, Hoel G, Moutet F, Ravet D (1982). Fractures of the fifth metacarpal neck. Annales de Chirurgie de la Main, 1: 221–226. Galanakis I, Aligizakis A, Katonis P, Papadokostakis G, Stergiopoulos K, Hadjipavlou A (2002). Treatment of closed unstable metacarpal fractures using percutaneous transverse fixation with Kirschner wires. Journal of Trauma, 55: 509–513. Greer SE, Williams JM (1999). Boxer’s fracture: an indicator of intentional and recurrent injury. American Journal of Emergency Medicine, 17: 357–360. Konradsen L, Nielsen PT, Albrecht-Beste E (1990). Functional treatment of metacarpal fractures: 100 randomised cases with or without fixation. Acta Orthopaedica Scandinavica, 61: 531–534. Lamb WL, Abernethy PA, Raine PAM (1973). Unstable fractures of the metacarpals; a new method of treatment by transverse wire fixation to intact metacarpals. The Hand, 1: 43–48. Lowdow IM (1986). Fractures of the metacarpal neck of the little finger. Injury, 17: 189–192. Manueddu CA, Della Santa D (1996). Fasciculated intramedullary pinning of metacarpal fractures. Journal of Hand Surgery, 21B: 230–236. McKerrel J, Bowen V, Johnston G, Zondervan J (1987). Boxer’s fractures conservative or operative management? Journal of Trauma, 27: 486–490. Mercan S, Uzun M, Ertugrul A, Ozturk I, Demir B, Sulun T (2004). Psychopathology and personality features in orthopaedic patients with boxers fractures. General Hospital Psychiatry, 27: 13–17. Meunier MJ, Hentzen E, Ryan M (2004). Predicted effects of metacarpal shortening on interosseous muscle function. Journal of Hand Surgery, 29A: 689–693. Mitz V, Richard JC, Ohanna J, Vilain R (1981). Inte´reˆt de l’oste´osynthe`se par brochage transversal externe des fractures du cinquie`me me´tacarpien. Revue de Chirurgie Orthope´dique, 67: 571–576. Smith NC, Moncrieff NJ, Hartnell N, Ashwell J (2003). Pseudorotation of the little finger. Journal of Hand Surgery, 28B: 395–398. Trabelsi A, Dusserre F, Ascensio G, Bertin R (2001). Traitement orthope´dique de fractures du col du cinquie`me me´tacarpien: e´tude prospective. Chirurgie de la Main, 20: 226–230. Vichard P, Tropet Y, Nicolet F (1981). About fractures of the neck of the fifth metacarpal bone. Annales de Chirurgie, 35: 783–787. Waugh RL, Ferrazano GP (1943). Fractures of the metacarpals; exclusive of the thumb: a new method of treatment. American Journal of Surgery, 59: 186–194. Received: 16 July 2005 Accepted after revision: 13 July 2007 Dr Matthias Winter, Service de Traumatologie, PC medical 3e`me D, Hoˆpital St Roch, 5 rue Pierre De´voluy, 06000 NICE, France. Tel.: +33 620983981. E-mail: [email protected], [email protected].
r 2007 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhse.2007.07.011 available online at http://www.sciencedirect.com
The purpose of this study was to compare the surgical treatment of fractures of the little finger metacarpal neck, or ‘‘Boxer’s’’ fractures, by transverse pinning and intramedullary pinning. Thirty-six patients with fracture of the neck of the fifth metacarpal were included in a prospective comparative randomised study. A palmar splint was applied for 1 week after both procedures. Patients began physiotherapy three times per week for 30 days. The patients were evaluated clinically six times after surgery, up to the 90th day, with X-ray assessment on days 8, 45 and 90. The study showed that intramedullary pinning gave better functional outcomes than transverse pinning, although the former was more technically demanding. Journal of Hand Surgery (European Volume, 2007) 32E: 6: 709–713 Keywords: boxer’s fracture, metacarpal bone, transverse pinning, intramedullary pinning
Fractures of the neck of the fifth metacarpal, the socalled ‘‘Boxer’s Fracture’’, are very common injuries of the hand. The patients are usually active young men and these are typical injuries of aggression/alcohol intake (Greer and Williams, 1999; Mercan et al., 2004). Commonly, the dominant hand is the punching hand and this hand is affected. When palmar angulation exceeds 451, or when the patient presents a rotational deformity of the little finger in flexion, reduction, with or without surgical treatment, is mandatory (Ali et al., 1999). Foucher et al. (1976) reported fixation of these fractures by the insertion of fine K-wires antegradely to avoid the metacarpal articular surface. Foucher (1995) later reported a series of 66 cases treated in this manner and called this the ‘‘Bouquet’’ technique. Berkman and Miles (1943) first described the transverse pinning technique of little finger metacarpal neck fracture fixation in which several K-wires are passed transversely between the fifth and the fourth metacarpal to stabilise the fracture. It is known that these techniques are both efficient, but no comparison between them has been published. The purpose of this prospective study was to compare the two procedures in terms of functional and radiological outcome.
closed and simple fracture of the neck of the little finger metacarpal bone. Open fractures and fractures extending to the metacarpal shaft, or to the articular surface, were excluded from the study. Patients presenting with multiple injuries, fifth metacarpal malunion and selfinflicted injuries were not included in the study. Rotational deformity of the little finger was assessed clinically. In flexion, malrotation was recorded if the little finger was not oriented towards the scaphoid tubercle. In extension, the plane of orientation of the fifth finger nail relative to the other finger nails was noted: malrotation was recorded if these were not parallel. The palmar angular displacement of the fracture was measured on a lateral oblique X-ray with a goniometer placed on the dorsal cortical line of the metacarpal. Surgery was indicated if clinical malrotation of the little finger existed, or if the palmar angulation of the fracture exceeded 301. Operative procedure Patients underwent either transverse pinning or intramedullary pinning by the Bouquet technique. Infraclavicular brachial block anaesthesia was used in all cases. The technique chosen was allocated using a randomisation table. Each patient was registered in the table in the order of his/her inclusion in the study and allocated to one or other treatment group accordingly. Before inclusion, a written consent was obtained and the patient was informed about the surgical procedure. Patients were operated on by the senior surgeons of the department or by junior surgeons under supervision of a senior surgeon.
PATIENTS AND METHODS Patients The study was of a consecutive series of patients during a period of 12 months between 2003 and 2004. The clinical criterion for inclusion was a recent, isolated, 709
ARTICLE IN PRESS 710
Intramedullary pinning (the ‘Bouquet’ technique) For intramedullary pinning, three K-wires, of diameter 1 mm were used. These wires were contoured in order to obtain a 201 distal angulation. A small incision was made at the level of the carpometacarpal joint. After drilling a hole in the base of the little finger metacarpal, the wires were introduced into the metacarpal shaft. The distal angulation of the first wire was oriented dorsally. The two other wires were oriented in a radial and an ulnar direction, respectively. Clinical and X-rays checks of the adequacy of fracture fixation and the rotational position of the finger were carried out. The K-wires were then bent, cut and buried subcutaneously (Fig 1). Transverse pinning For transverse pinning, two K-wires of diameter 1.5 mm were used. The first K-wire was introduced through the ulnar border of the hand and passed from the little to the ring metacarpal shaft, approximately 10 mm proximal to the fracture. After reduction, the second K-wire was introduced through the ulnar border of the hand and passed from the little to the ring metacarpal head, avoiding the articular surfaces. This second wire was passed parallel to the first. The position of the finger in extension and flexion was then examined to check the rotation. Final clinical and X-ray checks of the adequacy of fracture fixation and the rotational position
Fig 1 Intramedullary pinning of a little finger metacarpal neck fracture.
Fig 2 Transverse pinning of a little finger metacarpal neck fracture.
THE JOURNAL OF HAND SURGERY VOL. 32E No. 6 DECEMBER
2007
of the finger were carried out. The K-wires were then cut and buried subcutaneously (Fig 2). Postoperatively, as recommended by Galanakis et al. (2002), a palmar splint was applied for 1 week after both procedures in order to assist healing of the soft tissues and to avoid postoperative displacement of the fracture (Faraj and Davis, 1999). After removal of the splint, patients began physiotherapy three times per week with the little and ring fingers buddy-strapped. The buddy-strapping was removed at the day 30 examination. The surgical stabilisation enables such early mobilisation of the hand to avoid stiffness without risk of secondary displacement (Konradsen et al., 1990; Vichard et al., 1981). After both procedures, the K-wires were removed 6 weeks after surgery under local anaesthesia. The patients were evaluated clinically on days 8, 15, 30, 45, 60 and 90 after surgery, with X-ray assessment, using an anteroposterior view and a lateral oblique hand X-ray, on days 8, 45 and 90. Pain was evaluated at each visit using a visual analogue scale from 0 to 10 in which 0 was no pain at all and 10 was the worst pain the patient could imagine. Active and passive ranges of motion of all three joints of the fifth ray were measured individually with a goniometer at each review by the physiotherapist. The grip strength of both hands was measured with a Jamart dynamometer on days 15, 30, 45, 60 and 90 after surgery. Postoperative rotation of the little finger was evaluated using the same criteria as were used for preoperative assessment.
ARTICLE IN PRESS SURGICAL TREATMENT OF THE BOXER’S FRACTURE
711
At each X-ray review, the angulation of the fracture was measured on lateral oblique hand X-rays. Fracture union was sought at each X-ray review. Fracture was considered as united when bone trabeculae crossing the fracture were noticed. Patient satisfaction was evaluated at the last review as excellent, good, fair or poor. If present, complications were noticed at each review. Data were expressed as mean and lower to upper values. The statistical tests used were a Fisher’s exact test, a Mann Withney U-test or a repeated measures ANOVA if required. A p Value under 0.05 was considered as significant. Because of the lack of previously published data, we were unable to calculate a sample size for this preliminary study.
RESULTS Thirty-six patients were included during a period of 12 months. Eighteen underwent transverse pinning and 18 underwent intramedullary pinning. All the patients were men, of mean age 31.4 (range 18–65) years. Twenty-four patients presented with a rotational deformity of the little finger. The average palmar angulation of the fracture preoperatively was 531 (range 301–901). 300 250
transverse intramedullary 246
TAM (degrees)
280 257
280 261
Day 60
Day 90
233
226
213
200
274
262
196 169
150 100 50 0
Day 8
Day 15
Day 30
Day 45
Fig 3 Comparison of total active motion (TAM) between the two groups.
The average period of immobilisation was 8.6 (range 0–30) days. Mean follow-up was 2.7 (range 2–3) months. The two groups were comparable in terms of follow-up duration. At final follow-up, two patients had residual pain measuring 1 and 4 on the visual analogue scale, respectively. Both had been treated by transverse pinning. At final follow-up, the mean total passive motion was 2851 (range 2001–3251) and the mean total active motion (TAM) was 2701 (range 1901–3101). All of the patients achieved full extension of the little finger. TAM showed a significant difference between the two groups, with a better result in the intramedullary pinning group (p ¼ 0.02) (Fig 3) (Table 1). The active range of motion of the metacarpophalangeal (MCP) joint was also significantly different between the two procedures, with a better result in the retrograde intramedullary pinning (p ¼ 0.0037) (Fig 4) (Table 1). One patient in the intramedullary pinning group removed his splint immediately after leaving the hospital and two patients in the transverse pinning group kept their splint on for one month because they did not come for review until this date. Grip strength was stronger after intramedullary pinning than after transverse pinning, but the difference was not statistically significant (Table 1). No patients had malrotation of the little finger postoperatively. A residual palmar angulation was found in 12 patients, with a mean palmar angulation of 91 (range 51–201). Five of the 18 patients in the transverse pinning group still had a mean palmar angulation of 101 (range 51–201). Seven of the 18 patients in the intramedullary pinning group still had a mean palmar angulation of 81 (range 51–151). Two patients from the transverse pinning group suffered secondary displacements of the fractures at the first X-ray assessment. However, this did not influence the postoperative care, because the angulations were minimal, and there was no malrotation. All fractures united within the period of 6 weeks. In terms of patient satisfaction, 28 patients considered their result as good or excellent. Data about satisfaction was absent for three patients. Thirteen of 17 patients in
Table 1—Comparative data of the two groups
Age mean (range) (years) Pre-operative angulation (1) Rotational problems Postoperative immobilization (days) TAM at final follow-up Active ROM MCPj at final follow-up Percentage of contralateral grip strength Statistically significant difference.
Intramedullary fixation (n ¼ 18)
Transverse fixation (n ¼ 18)
p Value
30.8 (18–65) 54.7 (30–90) 67% 7 (SD ¼ 2.3) 2791 (SD ¼ 11.9) 941 (SD ¼ 5.9) 92%
32 (20–49) 50.8 (30–70) 67% 10 (SD ¼ 7.7) 2611 (SD ¼ 36.5) 81.51 (SD ¼ 19.4) 83%
0.66 0.09 0.12 0.02 0.0037 0.06
ARTICLE IN PRESS 712
THE JOURNAL OF HAND SURGERY VOL. 32E No. 6 DECEMBER
100
transverse
ROM MCP joint (degrees)
90
intramedullary
80
78
80
68
70
95
94
90
82
66 60
60
48
50 40
42 36
30 20 10 0 Day 8
Day 15
Day 30
Day 45
Day 60
Day 90
Fig 4 Comparison of active ranges of motion of the MCP joint between the two groups.
the transverse pinning group and 15 of 16 patients in the intramedullary pinning group for whom satisfaction data was available had good or excellent results. Three poor and one fair result were noted in the transverse pinning group. One fair result was found in the intramedullary group (Table 1). There were no postoperative infections or digital nerve neuropraxias in either group. One patient in the transverse pinning group developed CRPS type 1 (syn. reflex sympathetic dystrophy, algodystrophy) after having worn his splint for 4 weeks without coming for review. This patient was involved in worker’s compensation. In respect of age, the angulation of the fracture, the malrotation, the time of immobilisation, the grip strength and the postoperative pain at final follow-up, there were no significant differences between the two groups.
DISCUSSION Fractures of the neck of the fifth metacarpal bone usually occur as a result of punching or in a fall (Greer and Williams, 1999). This injury has been described as ‘‘a tolerable fracture in an intolerable patient’’ (Mercan et al., 2004). Palmar displacement of the fifth metacarpal head and metacarpal shortening as a result of this fracture can occasionally have detrimental effects on hand function (Ali et al., 1999; Birndorf et al., 1997; Meunier et al., 2004). According to biomechanical studies, such displacement can alter the intrinsic muscle and the tendon balance, leading to a loss of grip strength and an extension deficit. The management of the boxer’s fracture is still controversial. Conservative treatment gives good results for fractures presenting with small displacement (Lowdow, 1986; McKerrel et al., 1987). Ali et al. (1999) and Birndorf
2007
et al. (1997) suggested that 301 is the upper limit of acceptable angulation of palmar displacement of such fractures. With respect to this trial, we included all patients with angulation of 301 or more, although the degree of angulation at which active treatment is considered to be mandatory remains controversial. Rotational displacement of the fifth ray following such fractures typically requires reduction. Recently, Smith et al. (2003) have shown that soft tissue swelling can induce a rotational problem by itself, without any fracture. We believe it is important to re-examine these patients after a week of treatment intended to reduce swelling. In face of severely displaced fractures, some authors suggest treatment by external reduction followed by immobilisation (Trabelsi et al., 2001). Unfortunately, external manipulation, even protected by a cast, often leads to secondary displacement (Lowdow, 1986). Many different surgical procedures have been described for treating this fracture (Berkman and Miles, 1943; Calder et al., 2000; Faraj and Davis, 1999; Foucher et al., 1976), but two attitudes can be identified. The first consists in using the ring finger metacarpal bone as a splint to maintain the fracture reduction using transverse K-wiring. The second is to stabilise the little finger metacarpal itself after adequate reduction by use of techniques of direct bone fixation, including axial, intramedullary K-wiring (the ‘Bouquet’ technique). Transverse pinning has been described by a number of authors (Berkman and Miles, 1943; Lamb et al., 1973; Mitz et al., 1981; Waugh and Ferrazano, 1943). The technique was described most precisely by Lamb et al. (1973). It is an easy procedure, which has many advantages: it is simple and quick, it provides good stability, is not very painful and has a low learning curve for the surgeon. One the other hand, it has some problems. The distal K-wire may damage the MCP articulation, especially for distal fractures. Introducing a K-wire through the intermetacarpal space may damage the interosseous muscles. Involvement of the ring metacarpal in the fixation makes movement between the two ulnar metacarpal bones impossible and, so, may reduce mobility of the hand. This, perhaps, is the reason for the poorer functional outcome with this technique when compared to intramedullary pinning. All of the patients in this series were operated on under brachial plexus block. However, transverse pinning can easily be done under local anaesthesia. Intramedullary pinning of the fifth metacarpal bone was described by Foucher et al. (1976). Later, the senior author published a series of 66 patients treated in this way with good results (Foucher, 1995). Since then, many other series using intramedullary pinnings have been described (Frere et al., 1982; Barry et al., 1991; Beal et al., 1991; Faraj and Davis, 1999; Manueddu and Della Santa, 1996). This procedure is more demanding technically than transverse pinning and, therefore, the surgeon has a more definite learning curve. Complications such as
ARTICLE IN PRESS SURGICAL TREATMENT OF THE BOXER’S FRACTURE
articular surface damage are more frequent with this technique. The surgical approach may also endanger branches of the dorsal branch of the ulnar nerve. Nevertheless, with the ring and little finger rays remaining independent, motion of both rays remains excellent. This procedure provides solid reduction and gives good anatomical reduction and, so, good results. This study suggests that intramedullary pinning is a particularly efficient procedure for treatment of the boxer’s fracture. Although more demanding, it has shown better results than transverse pinning. The difference between the two techniques in terms of early motion is probably explained by the independent mobility of the two metacarpal bones. Two weeks after removal of the wires, we noted that the difference of TAM and TPM between the two groups decreases. However, at 3 months, the functional results remained slightly better in the intramedullary pinning group. References Ali A, Hamman J, Mass DP (1999). The biomechanical effects of angulated boxer’s fractures. Journal of Hand Surgery, 24A: 835–844. Barry P, Regnard PJ, Bensa P (1991). Bundled wiring in fractures of the neck of the fifth metacarpal: 5 cases. Annales de Chirurgie de la Main et du Membre Supe´rieur, 10: 469–475. Beal D, Rongieres M, Mansat M (1991). Bundled central medullary bone wiring. Method of choice in the treatment of fractures of the neck of the fifth metacarpal necessitating a reduction: 30 cases. Annales de Chirurgie de la Main et du Membre Supe´rieur, 10: 463–468. Berkman EF, Miles GH (1943). Internal fixation of metacarpal fractures exclusive of the thumb. Journal of Bone and Joint Surgery, 25: 816–821. Birndorf MS, Daley R, Greenwald DP (1997). Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. Plastic and Reconstructive Surgery, 99: 1079–1083. Calder JDF, O’Leary S, Evans SC (2000). Antegrade intramedullary fixation of displaced fifth metacarpal fractures. Injury, 31: 47–50. Faraj AA, Davis TRC (1999). Percutaneous intramedullary fixation of metacarpal shaft fractures. Journal of Hand Surgery, 24B: 76–79. Foucher G (1995). ‘‘Bouquet’’ osteosynthesis in metacarpal neck fractures. A serie of 66 patients. Journal of Hand Surgery, 20A: 86–89. Foucher G, Chemorin C, Sibilly A (1976). Nouveau proce´de´ d’oste´osynthe`se original dans les fractures du tiers distal du cinquie`me me´tacarpien. Nouvelle Presse Me´dicale, 17: 1139–1140.
713
Frere G, Hoel G, Moutet F, Ravet D (1982). Fractures of the fifth metacarpal neck. Annales de Chirurgie de la Main, 1: 221–226. Galanakis I, Aligizakis A, Katonis P, Papadokostakis G, Stergiopoulos K, Hadjipavlou A (2002). Treatment of closed unstable metacarpal fractures using percutaneous transverse fixation with Kirschner wires. Journal of Trauma, 55: 509–513. Greer SE, Williams JM (1999). Boxer’s fracture: an indicator of intentional and recurrent injury. American Journal of Emergency Medicine, 17: 357–360. Konradsen L, Nielsen PT, Albrecht-Beste E (1990). Functional treatment of metacarpal fractures: 100 randomised cases with or without fixation. Acta Orthopaedica Scandinavica, 61: 531–534. Lamb WL, Abernethy PA, Raine PAM (1973). Unstable fractures of the metacarpals; a new method of treatment by transverse wire fixation to intact metacarpals. The Hand, 1: 43–48. Lowdow IM (1986). Fractures of the metacarpal neck of the little finger. Injury, 17: 189–192. Manueddu CA, Della Santa D (1996). Fasciculated intramedullary pinning of metacarpal fractures. Journal of Hand Surgery, 21B: 230–236. McKerrel J, Bowen V, Johnston G, Zondervan J (1987). Boxer’s fractures conservative or operative management? Journal of Trauma, 27: 486–490. Mercan S, Uzun M, Ertugrul A, Ozturk I, Demir B, Sulun T (2004). Psychopathology and personality features in orthopaedic patients with boxers fractures. General Hospital Psychiatry, 27: 13–17. Meunier MJ, Hentzen E, Ryan M (2004). Predicted effects of metacarpal shortening on interosseous muscle function. Journal of Hand Surgery, 29A: 689–693. Mitz V, Richard JC, Ohanna J, Vilain R (1981). Inte´reˆt de l’oste´osynthe`se par brochage transversal externe des fractures du cinquie`me me´tacarpien. Revue de Chirurgie Orthope´dique, 67: 571–576. Smith NC, Moncrieff NJ, Hartnell N, Ashwell J (2003). Pseudorotation of the little finger. Journal of Hand Surgery, 28B: 395–398. Trabelsi A, Dusserre F, Ascensio G, Bertin R (2001). Traitement orthope´dique de fractures du col du cinquie`me me´tacarpien: e´tude prospective. Chirurgie de la Main, 20: 226–230. Vichard P, Tropet Y, Nicolet F (1981). About fractures of the neck of the fifth metacarpal bone. Annales de Chirurgie, 35: 783–787. Waugh RL, Ferrazano GP (1943). Fractures of the metacarpals; exclusive of the thumb: a new method of treatment. American Journal of Surgery, 59: 186–194. Received: 16 July 2005 Accepted after revision: 13 July 2007 Dr Matthias Winter, Service de Traumatologie, PC medical 3e`me D, Hoˆpital St Roch, 5 rue Pierre De´voluy, 06000 NICE, France. Tel.: +33 620983981. E-mail: [email protected], [email protected].
r 2007 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhse.2007.07.011 available online at http://www.sciencedirect.com